Primary Extradural Tumours

and Metastasis of the Spine

Cody Bünger

Spine Center/Sarcoma Center

Aarhus University Hospital, Aarhus Sygehus

Denmark

Klassifikation af ekstradurale spinale

tumorer

• Benigne

OsteokondromOsteoid osteomOsteoblastomAneurysmatisk knoglecysteKæmpecelletumorHæmangiomEosinofilt granulom

Neurofibrom

• Primære maligne

Chordom

Pagetic Sarcoma

Kondrosarkom

Osteogent sarkom

Ewings sarkom

Plasmacytom

Myelom

Malignant Schwannoma

• Metastaser

”Abnormal” tumour behaviour in

The Spine

• Aneurysmatic bone cysts

• Hemangioendothelioma

• Giant cell tumour

• Osteochondroma

• Eosinophilic granuloma

When to suspect a primary bone

tumour of the spine ?

• Solitary tumour

• Pain

• Neurology

• Age

Vertebral Plana

Osteomyelitis

Ewing Sarcom

Lymphom

Aneurysmal bone Cyst

Acute Leukemia

Metastatic lesion

Eosinophilic granuloma (Langerhans Cell Histiocytosis)

Extradural Primary Tumours of the

Spine

• Detection (X-ray, MRI/CT, blood tests)

locally.

• Biopsi, classification and treatment by

Sarcoma Center (RH or Aarhus)

Cross disciplinary team:

• Oncologist, radiologist, orthopedic

surgeons, pathologist, pediatrician

General Assessment in Extradural

Spinal Tumors

• Clinical

• Full skeletal x-ray

• 99tc-MDP scan

• Pulmonary CT

• Ultrasound abdomen

• ESR, CRP, PSA, IgM,

alk. phosphatase and

white cell count

• Total spine MRI

• CT -spine

• WBB classification

• Tomita classification.

• Tokuhashi score

• GSTSG score

Diagnosis of Extradural Spinal

Tumors

• CT guided biopsy

• FNA -fine needle aspirate

• Transpedicular trocal biopsy

• Extralesional én bloc resection

• Often immuno-histochemical stainings

• Subclassification of primary tumor

EXTRADURAL PRIMARY

TUMOR

DIFFERENTIAL DIAGNOSIS

• Lymphoma/Plasmacytoma

• Spinal metastasis

• Spondylitis

• Osteonecrosis

• Osteoporotic fracture

• Ecchinococcus cysts

• Intradural metastasis

Surgical Methods in Extradural

Spine Tumors

• Laminectomy

• Curettage

• Piecemeal resection

• Intralesional én bloc resection

• Extralesional total én bloc resection

Followed by reconstruction of spinal columns

Radiotherapy

• Preop, perop or postoperative

• Intraoperative radiotherapy (IORT)

• Fractionated external radiotherapy (FERT)

• Incidence of radiation myelopathy:

0.2 – 0.5%/50Gy

5%/57 – 61Gy

50%/68 – 73 Gy

ANTERIOR CORPORECTOMY

Total vertebrectomy and reconstruction

Rene Louis

TOMITA TECHNIQUE

International Orthopedics (SICOT) (1994) 18 291-298

TOMITA TECHNIQUE

Lateral Extralesional en-Bloc Resection

Lateral Extralesional en-Bloc

Resection

The Aarhus - EN BLOC RESECTION

TOTAL EN BLOC RESECTION

Ewing's Sarcoma

(Emil, 090703-****)

Ewing's Sarcoma (Emil, 090703-****)

11-12-2009

Ewing‘s Sarcoma (Emil, 090703-****)

25-05-2010

Local Recurrence

Extralesional èn Bloc Resection

versus Intralesional

• Chondrosarcoma 20 % versus 100%

• Chordoma 33 % v 75 -100%

• Ewing 25%

• Osteogenic Sarcoma 20% v 60%

• Giant Cell Tumour 18% v 83%

Primary Extradural Tumours of

the Spine

Conclusions

• Rare

• Wrong decision making may have fatal

results

• Early referal to Sarcoma Center for

diagnosis and treatment:

(oncology/surgery/oncology)

CB-2010

SPINAL METASTASIS

Algoritms of treatment

Cody Bünger, Miao Wong, Kristian

Høy, Ebbe Stender Hansen, Yu Wang.

Spine Section, Aarhus, DK

SICOT 2008 -11

SOA 2011 Abha

65 y old female with breast cancer

and pain in the shoulders

Postop

Tokuhashi ScorePrognosis of expected survival time

in MSSC.

Tokuhashi SPINE 1990 15:1110-1113

The Aarhus

Surgical Strategy

Survival difference in between patients

admitted mobile and immobile.

0 200 400 600 800 1000 1200

Days

0.0

0.2

0.4

0.6

0.8

1.0

Results:

Comparison of Accuracy Rate

Roy A Patchell, Phillip A Tibbs, William F Regine,

Richard Payne, Stephen Saris Richard J

Krysscio, Mohammed Mohiuddin, Byron Young.

Direct decompressive surgical resection in the

treatment of spinal cord Compression caused by

metastatic cancer a randomized trail.

Lancet 2005; 366:643-48

SPINAL TUMORER

Giant Cell Tumour in a Child

Giant Cell Tumour

Chordoma

•Giant cell tumor

•Ewing sarcoma

•Chordoma

•Metastasis

Ewing's Sarcoma (Emil, 090703-****)

23-04-2010

Ewing's Sarcoma (Emil, 090703-****)

04-05-2010

Survival analysis

p=0.0495 Log-rank test

44 patients (M:F= 20: 24) Since March 12, 1992 to June 25, 2009

Blue: Extralesional group 32 patientsRed: Intralesional group 12 patients

Commonest tumor types: Chondrosarcoma (10), Osteoblastoma (5), Osteoid osteoma (5), Ewing's sarcoma (4), Chordoma (3), Osteosarcoma (3), giant cell tumor (3)

Local Recurrence

Intralesional versus èn Bloc

Resection

• Chondrosarcoma 20 % versus 100%

• Chordoma 33 % v 75 -100%

• Ewing 25%

• Osteogenic Sarcoma 20% v 60%

• Giant Cell Tumour 18% v 83%

Survival analysis

patients ≤30 years, n=22

p= 0.0016 Log-rank test

Patients > 30 years, n=22

p= 0.8600 Log-rank-test

Survival analysis

Tomita K et al 2009